Drug-Induced Sleep Endoscopy and Surgical Outcomes: A Multicenter Cohort Study.

OBJECTIVE: To evaluate the association between findings of blinded reviews of preoperative drug-induced sleep endoscopy (DISE) examinations using the VOTE Classification and obstructive sleep apnea (OSA) surgical outcomes in a large multicenter, international cohort. METHODS: Retrospective, multi-center cohort study of adults without tonsillar hypertrophy who underwent pharyngeal surgery for OSA. The study included only participants without enlarged tonsils. Four independent reviewers performed blinded review of preoperative DISE videos using the VOTE Classification system and scoring of a primary structure contributing to airway obstruction. DISE findings were examined for an association with surgical outcomes with univariate analyses and multiple regression. RESULTS: Two hundred seventy-five study participants were included from 14 centers. Mean age was 51.4 ± 11.8 years, and body mass index was 30.1 ± 5.2 kg/m2 . There was moderate interrater reliability (kappa = 0.40-0.60) for DISE findings. Oropharyngeal lateral wall-related obstruction was associated with poorer surgical outcomes (adjusted odds ratio (AOR) 0.51; 95% CI 0.27, 0.93). Complete tongue-related obstruction was associated with a lower odds of surgical response in moderate to severe OSA (AOR 0.52; 95% CI 0.28, 0.98), with findings that were similar but not statistically significant in other analyses. Surgical outcomes were not clearly associated with the degree and configuration of velum-related obstruction or the degree of epiglottis-related obstruction. Surgical response was associated with tonsil size and body mass index (inversely). CONCLUSION: DISE findings concerning the oropharyngeal lateral walls and tongue may be the most important findings of this evaluation technique. LEVEL OF EVIDENCE: 2B Laryngoscope, 129:761-770, 2019.

Application of drug-induced sleep endoscopy in patients treated with upper airway stimulation therapy.

OBJECTIVE: To determine the level of agreement among experienced operators of candidacy for upper airway stimulation (UAS) based on evaluation of drug-induced sleep endoscopy (DISE). METHODS: The trial was designed as a single-blinded cross-sectional study. Four otolaryngologists with extensive DISE experience were given 63 video clips from the STAR trial video library. These videos were graded using the VOTE classification. Percentage agreement and Cohen's κ (for inter-rater reliability) were calculated between pairs of reviewers, assessing palatal complete concentric collapse (CCC) and determining UAS eligibility. Subjects were also grouped based on collapse severity for each reviewer. RESULTS: The reviewers had excellent (approximately 90%) agreement on findings at the level of the soft palate and tongue base. The inter-rater reliability for palatal CCC ranged from moderate to substantial. The agreement on determining the criteria for UAS implantation ranged from poor to moderate. All 4 upper airway structures as classified by the criteria of the VOTE were graded by all the reviewers as contributing to obstruction in a majority of subjects who were performed via application of DISE. CONCLUSION: Application of DISE remains a subjective examination, even among those experienced operators, therefore more studies need to be performed for evaluation of improvement in inter-rater reliability after implantation of training videos.

Structural effectiveness of pharyngeal sleep apnea surgery.

Obstructive sleep apnea results from the combination of a structurally small upper airway combined with the loss of muscle tone during sleep. Most therapies aim to reduce apnea severity by increasing airway size and stability. Conceptually, upper airway surgery should be a highly effective method to treat obstructive sleep apnea and other forms of sleep disordered breathing. Although major reconstructive surgeries such as maxillomandibular advancement demonstrate high success rates, more limited forms of surgery often demonstrate significantly lower success rates. Reviews of such surgical procedures have uniformly ignored contributions of the structural effectiveness of surgery. The purpose of the review is to evaluate current knowledge of how surgery for OSA alters structure. The majority of data available on surgical outcomes involve uvulopalatopharyngoplasty. Data demonstrate that pre-morbid surgical anatomy and techniques have significant effects on ultimate outcomes. Further research on structural outcomes for palatopharyngoplasty, as well as other surgical procedures, is needed to improve clinical outcomes.

Acute effects of palatopharyngoplasty on airway collapsibility.

OBJECTIVE: The lateral pharyngeal walls contribute to obstruction in obstructive sleep apnea. These structures may be unaffected by uvulopalatopharyngoplasty. This was evaluated by retrospective review of upper airway observations after palatopharyngoplasty. METHODS AND PATIENTS: The retropalatal airway was endoscopically observed intraoperatively after each procedure in 7 patients. The airway was dilated with nasal continuous positive airway pressure. RESULTS: Transpalatal advancement pharyngoplasty increased the area 120% (P = 0.001), and closing pressure decreased 9.2 cm H2 O (P < 0. 01). The maximal anteroposterior length (MAX-AP) and maximal lateral radius increased 90% (P = 0.01) and 60% (P < 0.001), respectively. MAX-AP changed in 2, both increased in 4, and maximal lateral radius increased in 1 patient. The closing pressure change correlated with airway size (r 2 = 0.44, P < 0.05); airway shape was associated with change in MAX-AP (r 2 = 0.51, P < 0.07). CONCLUSIONS: Both the anteroposterior and lateral wall dimensions are altered by palatopharyngoplasty techniques, which increase retropalatal airway size. This is not limited to facial advancement surgery.